- Laser = light amplification by stimulated emission of radiation
- Focalized high energy → instant coagulation → reduced bleeding, sparing of healthy tissues
Type of Lasers
|Type of laser||Wavelength (nm)||Features||Type of surgery|
|CO2||10,600||High vaporization superficially, little damage to deep tissues||Oropharyngeal surgery, vocal cord surgery|
|Nd:YAG||1,064||Further spread, greater coagulation versus vaporization||Tumor debulking, tracheal procedures|
|Ruby||694||Absorbed primarily by dark pigments||Retinal surgery|
|Argon||515||Transmitted by water, absorbed by hemoglobin||Vascular lesions|
- Complete NMB of vocal cords
- Inhibition of pharyngeal reflexes
- Decrease secretions (glycopyrrolate 0.2–0.4 mg IV)
- If intubation, prefer special laser ETT (metal-coated, double cuff, small diameter); inflate cuff(s) with colored saline
- If no intubation, typically transglottic jet ventilation
- Iatrogenic injury to patient can be caused by laser:
- Pneumothorax, blood vessel puncture, hollow viscus (trachea) rupture
- Dental injury
- Eye injury is of special concern, to both patient and health care provider:
- Window to OR door should be covered
- Everyone in OR (including patient) should wear appropriate wraparound goggles (Table below on Appropriate Eye Protection)
- Place wet eye pads on taped patient’s eyes and under goggles
Appropriate Eye Protection
|Type of laser||Structures damaged||Precautions|
- Gas is often used to cool laser probe tip
- Gas embolus can occur (especially during laparoscopic uterine surgery):
- Saline insufflation can be used, but fluid overload is possible
- Watch end-tidal CO2 closely. If embolus suspected, cease use of laser, support hemodynamics until embolus resolves
- Vaporized tissue can be inhaled by operating room personnel
- In theory, possible vector of infection (viruses) or malignant cells
- Consider use of high-efficiency filtration masks
Airway fire (ETT ignition):
- Prevention of airway fire:
- Limit FiO2 to lowest amount compatible with adequate patient oxygenation (21–40%)
- Avoid N2O (supports combustion)
- Use specially designed tube (if unavailable, wrap tube in metal foil)
- Encourage placement of moistened pledgets around cuff by surgeons
- Fill cuff with methylene blue–colored saline to provide surgeons with visible warning of cuff puncture
- Treatment of airway fire:
- Cease use of laser immediately
- Immediately disconnect tube from circuit. This should extinguish fire quickly:
- Extubate as soon as the fire is extinguished. If fire still persists after circuit disconnection, pour saline in mouth
- Place tube in water after extubation
- Reintubate patient:
- Airway damage may increase difficulty of intubation. Consider use of difficult airway equipment. Have surgeons prepare for tracheostomy if necessary
- Assess lung damage with bronchoscopy. Keep patient intubated postoperatively. Monitor arterial blood gases, chest radiograph; assess airway for swelling (consider steroid course)...
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